Access to Care
A Professional Imperative: Caring for the Oral Health of America's Children - Dr. David A. Nash

David A. Nash, DMD, MS, EdD

William R. Willard Professor of Dental Education Professor of Pediatric Dentistry University of Kentucky College of Dentistry

A Professional Imperative

There are a number of imperatives for learned
professions. However, the ultimate imperative was advanced
by Abraham Flexner, the father of modern American medical
education, when he said "professions are organs
contrived for the achievement of social ends rather than as
bodies formed to stand together for the assertion of rights
or for the protection and interests and privileges of their
members."1 The
"social end" currently at issue is ensuring that
all children have access to oral health care.

The imperative advanced above is one of the six
characteristics Flexner explicated, which subsequently
contributed to the twentieth century understanding as to
what constitutes a profession. Sociologically, a profession
is a profession; that is, it is to
profess—meaning to vow or
promise. Thus, learned professions and
professionals are understood to have promised society they
will use their learning and expertise to advance societal
well-being. Our profession has been granted a virtual
monopoly by society to practice dentistry as a result of
our vow to make the oral health of our patients
and of society our primary purpose. Consequently, dentistry
exists with a moral imperative—doing good. Caring for
the oral health of all Americans is dentistry's
professional calling. However, this responsibility is
particularly crucial in the context of caring for our
nation's children.

The Moral Priority of Children

Philosophers Kopleman and Palumbo have published a
thoughtful and compelling paper entitled "The U.S.
Health Delivery System: Inefficient and Unfair to
Children."2 The paper
explores the four major ethical theories of distributive or
social justice: utilitarianism, egalitarianism,
libertarianism, and contractarianism. The authors conclude
that no matter which theoretical stance you take, all
support the perspective that children should receive
priority consideration in receiving health care.

Norman Daniels, professor of bioethics and population
health at the Harvard School of Public Health, argues that
a just society should provide basic health care to all, but
redistribute health care more favorably to children.3 He justifies this conclusion
based on the effect health care has on equality of
opportunity for children, with equality of opportunity
being a fundamental requirement of justice.

The opportunity to realize one's full potential in life
is markedly affected by one's childhood. What happens in
the life of a child determines whether that child will have
a fair opportunity to fulfill his or her unique potential.
The worthiness of a society can be evaluated in terms of
its concern for and care of the health of its children.
President John F. Kennedy expressed it well, "Children
may be the victims of fate—they must never be the
victims of neglect." Today, many of our nation's
children are being neglected. Disparities exist between the
economically advantaged and the economically disadvantaged;
and many children do not have the benefit of oral health.4

Problems in Caring for the Oral Health of
America's Children

Caring for the oral health of America's children is a
multifaceted and complex problem. However, it is one for
which the profession must provide leadership, in tandem
with society, if our children are to grow to adulthood
having experienced oral health, and with the potential for
a lifetime of oral health. The current problem is
documented, in part, by the following statistics:

80 percent of the dental disease in children is
found 20-25 percent of children, and these are
primarily children from low income and minority
families, and there is a growing epidemic of early
childhood caries.5

As a result of the expansion of the Children's
Health Insurance Program and the Affordable Care Act,
40 million of America's 78.6 million children—the
majority—are becoming eligible for public insurance.6

Fewer than 25 percent of America's dentists will
treat a patient with public insurance; and of those who
do treat children with public insurance, only 9.5
percent bill more than $10,000/year.7-8

In the context of healthcare reform and the current
movement to expand the dental workforce, leaders in the
profession representing organized dentistry continually
affirm that the problem is primarily a financial one—one
that (evidently) only increased Medicaid/CHIP fees can
solve. A recent past president of the American Academy of
Pediatric Dentistry (AADP) affirmed that "there is no
access to care problem [for children] where dentists are
reasonably reimbursed."9 This is in contrast to the
evidence that an increase in professional fees paid by
public insurance only marginally improves dentists'
participation.10 The AAPD
past president went on to say: "The United States has
the best model of delivering care [to children] that
exists."9 The chair of the American Dental
Association's Council of Government Affairs commented that
"... the delivery system works extremely well for
Americans and should be left untouched by any reform
effort."11 He
continued, "... the fundamental problem with access to
dental care in America [is] improving funding for dental
services under Medicaid."

Dentistry is seeking a business model
solution—more money in our pockets—when society
clearly does not have any tolerance for devoting more money
to public insurance programs. As the current budget deficit
demonstrates, there is no more money. Our demand for
increases in public insurance fees is in the context of us
prospering economically in ways never before experienced.
The average net annual income of general dentists in 2008
was $207,210 and for pediatric dentists it was $346,070.12 Dentists rank in the top
1-2 percent of income earners in the United States. Our
professional speech and behavior seem to advocate for what
is best for us as dentists, reflecting the culture of a
business enterprise, rather than what is best for the oral
health of children—a professional culture.13 While there is clearly a
business dimension to managing a professional practice,
professions are not primarily businesses. The late Talcott
Parsons, considered the dean of modern sociology, expressed
it well: "The core criterion of a full-fledged
profession is that it must have means of ensuring that its
competencies are put to socially responsible uses ...
professionals are not capitalists...and they certainly are
not independent proprietors or members of proprietary
groups."14

Rashi Fein, the noted Harvard health economist expressed
distress at the transformation occurring in American
society. "A new language has infected the culture of
health care. It is the language of the marketplace, of the
tradesman, and of the cost accountant...It is a language
that is dangerous."15
Kenneth Arrow, emeritus professor at Stanford University,
won the Nobel Prize in economics in 1972 partly due to his
ability to demonstrate that health care cannot be
considered a commodity of the marketplace.16 Health care, including oral
health care, is not a business.

Society is simply exhausted with dentistry continuing to
say, essentially, "give us more money and leave us alone."
Public policy leaders and healthcare advocates are
responding that the current paradigm for delivering care to
children is just too expensive; particularly with the
majority of children now eligible for public funding
through Medicaid and the Children's Health Insurance
Program (CHIP). The time has come for the profession and
society to renegotiate their social contract. Society
cannot pay us more money to care for our economically
disadvantaged children; we dentists will accept no less. In
such a quandary the profession must lead in advancing a
model for an alternative delivery system that will enable
our children to be cared for within the financial resources
society can provide.

School-Based Pediatric Oral Health (Dental)
Therapists

One such strategy is expanding the dental team to
include a new member, a pediatric oral health (dental)
therapist; an individual uniquely trained to provide basic
primary care for children under the general supervision of
a dentist.17-18 A recent
report of the Pew Children's Dental Campaign identified
eight benchmarks for evaluating states' responses to the
crisis in dental health among America's disadvantaged
children. Among the benchmarks was the "authorization of a
new primary dental care provider."19 The reauthorization and
expansion of the Children's Health Insurance Program called
for an investigation into the use of "mid-level providers"
to increase access to care for children.20 Congress understood the
importance of oral health care for children as social
policy in that the dental provisions of the health care
reform (Affordable Care Act of 2010) focus on caring for
children.21

Therapists have provided basic primary care for children
in New Zealand in a school-based delivery system since
1923, when the first therapists (then called school dental
nurses) graduated from New Zealand's inaugural two year
training program.22 Since
then utilizing therapists to care for the oral health of
children has spread throughout the world. Over 50 countries
now count therapists as members of the dental team.23 New Zealand has an exemplary
record of caring for its children. In a recent year, 97
percent of its children were enrolled in the School Dental
Service and received their care from a therapist, and 56
percent of preschool children were seen by therapists in
their neighborhood school.24 A 2003 report by New Zealand's
Public Health Advisory Committee indicated that at the end
of a typical elementary school year essentially all school
children are free of dental caries, with carious teeth
having been restored or extracted.25

It is interesting to speculate on what the impact on the
oral health of our children would be if elementary schools
in America had a dental clinic, as in New Zealand, staffed
by a dental therapist and dental assistant. While
inadequate numbers of dentists willing to care for children
with public insurance is a barrier to children receiving
optimal dental care, parents are also a barrier. If
children are to receive care we must remove the obstacles
created by parents; for many of whom education and
(understandable) life circumstances are such that the oral
health of their children falls to a lower priority than
desirable.26 As Dr. James
Dunning, the dean of American public health dentistry, and
at one time dean of the Harvard School of Dental Medicine,
said over 40 years ago "any large-scale incremental
care plan for children, if it is to succeed, must be
brought to them in their schools."27

Today, school-based health programs are emerging as an
important dimension of the nation's health care delivery
system.28 The establishment
of school-based health centers is a significant dimension
of the Affordable Care Act, which is reforming our health
care system.21 The National
Assembly on School-Based Health Care is the nation's
leading advocacy body for overcoming the structural
barriers to children receiving health care by placing
health care in schools.29
In comparing the costs of school-based health care in New
Zealand provided by therapists, with private practice
office-based models staffed by dentists in the United
States, evidence suggests a public supported school-based
program in the United States staffed by therapists could
result in dramatic financial savings, while also providing
care for the overwhelming percentage of America's
school-children, as well as a significant number of
preschool children.17

Conclusion

Historically, the profession of dentistry has
distinguished itself, and has been faithful to its calling
as a profession, by strongly advocating for water
fluoridation to improve oral health. The time has now
arrived for the profession to advocate for a delivery
system that will enable all children to have access to
basic oral health care. School-based care utilizing
pediatric oral health (dental) therapists is a proven,
cost-effective strategy to accomplish this goal. It is a
strategy that will enable dentistry to address its
professional imperative.

References

1. Flexner A. Is social work a profession? School and
Society 1915:1(26):901-11.